February 6, 2012

Do Patients Pay When They Leave Against Medical Advice?

Study examines misconceptions of who picks up tab when patients walk out

There are ways in which patients who leave the hospital against medical advice wind up paying for that decision. Being saddled with the full cost of their hospital stay, however, is not one of them.

Insurance companies know this. Patients who walk out may know this. But many physicians, according to a study published in the Journal of General Internal Medicine, do not.

A survey of general internal medicine doctors at the University of Chicago Medicine found that two-thirds of residents and almost half of attending physicians believe that when a patient leaves the hospital against medical advice, insurance companies will not pay for the patient's hospitalization, leaving the patient liable for the full hospital bill.

"We have all heard this, and many physicians may have passed it on to their students, even to patients threatening to leave on their own," said study author Vineet Arora, MD, associate professor of medicine at the University of Chicago Medicine. "But a closer look revealed this to be a myth, a medical urban legend, albeit a pervasive one."

"This is a misconception that we need to correct," she added. When patients leave the hospital against their doctor's advice, "that indicates a breakdown in the doctor-patient relationship."

Co-author Gabrielle Schaefer, a third-year medical student at the University of Chicago, said some physicians even will use the financial obligation angle as a threat to persuade a patient to stay. "But when a physician provides misinformation in order to influence a patient's decisions – no matter how well intentioned – it compounds the loss of trust," she said.

Every year, 1 to 2 percent of patients admitted to U.S. hospitals leave against medical advice. The number of patients who do this seems to be increasing: from 264,000 patients in 1997, to 368,000 in 2007, to nearly 500,000 in 2011. Studies demonstrate that those who leave against medical advice, or AMA, are much more likely to die or be readmitted within 30 days.

The researchers, all from the University of Chicago Medicine, combed through the records of more than 46,000 patients admitted to the general medicine service at the medical center's adult hospital between July 2001 and March 2010. They found that 526 patients, about 1 percent, had left against doctor's orders.

Consistent with previous studies, most of these patients had government-funded insurance, either Medicare or Medicaid (78 percent), or no insurance (14 percent). The average hospital charge was nearly $28,000, of which insurance paid on average almost $6,000. (Most patients also owe a minimal co-pay.) So leaving against medical advice brought no additional financial burden to the patient.

Of the 453 insured patients who left AMA, payment was initially denied in only 18 cases. All of those cases involved problems with the bill, not with the patient's behavior. None of those patients were denied coverage for leaving against doctors' orders.

A survey of internal medicine residents and attending physicians, however, found many did believe payment would be denied and warned patients that they could be held financially responsible if they left against medical advice.

An expanded survey found similar beliefs among residents at other Chicago-area hospitals, with more than 40 percent agreeing that they "often or always inform patients that they may be held financially responsible if they leave AMA." Consent forms for patients leaving AMA from two area hospitals warned patients about possible financial consequences.

One member of the research team – John Schuman, MD, now at the University of Oklahoma School of Community Medicine – followed up the published study with a less formal survey.

"I thought it important to go to the source," he wrote in GlassHospital, his health care blog. "I called the insurance companies themselves. I talked with VPs and media relations people from several of the nation's largest private insurance carriers. Each of them told me that the idea of a patient leaving AMA and having to foot their bill is bunk."

"They were glad to tell me so," he added, "as this was a rare occasion of insurance companies looking magnanimous."